Basic Information
| Provider Information | |||||||||
| NPI: | 1942301130 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CASTRO | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | JANE SUNGA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CASTRO | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | JANE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2929 CALDER ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | BEAUMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 777021845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4098339797 | ||||||||
| FaxNumber: | 4096546886 | ||||||||
| Practice Location | |||||||||
| Address1: | 2400 HIGHWAY 365 | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | NEDERLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 776276249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4098339797 | ||||||||
| FaxNumber: | 4096546810 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 07/28/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N1576 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 212580903 | 05 | TX | MEDICAID |